Nomination Form

Nomination Form

Guidance for completing this form

This form is to be completed by the person nominating the beneficiary for a respite break to stay at Matt’s Respite Retreats caravan in Haven Park, Weymouth Bay. The person nominating must be either a Medical Professional for example a Doctor or Occupational Therapist with appropriate seniority in the organisation or with appropriate seniority within a relevant Charity who deals with Beneficiaries affected by cancer.

Criteria: The nominated beneficiary must:

1. have been diagnosed with cancer and undergoing treatment or has received treatment within the last six months

or

2. the beneficiary is terminally ill with cancer

Location:

Weymouth Bay, Caravan Park, Haven, DT3 6BQ. 2.5 miles from central Weymouth. Own transport is preferable but there is a bus stop outside the park gates.

Accommodation:

There are two bedrooms and two bathrooms and a communal living area with kitchen and lounge, all centrally heated. Sleeping is for four with an additional pull out in the lounge for two persons. There is a no smoking and no pets allowed policy.

Cancellations

The self-catering respite must be taken on the agreed date. There are multiple bookings for the caravan so once booked Matt’s Respite Retreats may not be able to change the date.

Matt’s Respite Retreats is providing a respite break for people living with cancer. Matt’s Respite Retreats does not provide any medical care whilst the beneficiary is staying in the caravan. The beneficiary and their carers must ensure they have appropriate measures in place e.g. bringing their own medicine required for the duration of the stay. The nearest GP surgery and hospital is located in Weymouth.

Nomination form for a break at Matt’s Respite Retreats – Weymouth Bay Haven

Your Information

Matt’s Respite Retreats (the organisation) collects personal information when a respite stay at the caravan is requested. Matt’s Respite Retreats will use the information in order to provide the service that is required. Matt’s Respite Retreats will not share personal information with any other third parties for marketing purposes. Matt’s Respite Retreats will store the information securely and will securely dispose of the paper form, one month after the beneficiary has had the respite break, unless there is a dispute or issue which requires the information to be held until resolved. Matt’s Respite Retreats will hold the beneficiary name, address and date of stay in an electronic database for a period of 6 years following the date of the stay for monitoring purposes. This is so Matt’s Respite Retreats can limit beneficiaries experiencing multiple stays at the respite. After 6 years from the date of the stay the personal details will be removed from the database.

Beneficiary details

Declaration by Nominee

I confirm that the above beneficiary I am nominating fits both criteria in the guidance and the personal details can be passed to Matt’s Respite Retreats in order that they can arrange a respite stay for the beneficiary as mentioned above. I confirm that the beneficiary is able to walk up two sets of steps and undertake a respite break.

Details of person and organisation nominating

One of the main ways Matt's Respite Retreats funds the Respite Breaks offered is by renting the caravan during the School Holidays.  Book a break and help us to provide more breaks to those affected by cancer.